Oak Grove Rehab and Skilled Care

Facility I.D. Number: 0041418
120 N. Tower Road
Carbondale, IL 62901

Date of Survey: 3/11/04

Incident Report Investigation of 2/29/04

“A” violation(s):

The facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being of the resident, in accordance with each resident’s comprehensive assessment and plan of care. Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident.

All necessary precautions shall be taken to assure that the residents’ environment remains as free of accident hazards as possible. All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents.

All exterior doors shall be equipped with a signal that will alert staff if a resident leaves the building. Any exterior door that is supervised during certain periods may have a disconnect device for part-time use. If there is constant 24 hour a day supervision of the door, a signal is not required.

These REGULATIONS are not met as evidenced by:

Based on record review, observation, and interview, the facility failed to provide adequate supervision to prevent the elopement of one resident (R1) from the sample of 8. R1, who is cognitively impaired and at risk for elopement, left the facility on 2/29/04 without staff knowledge.

The findings include:

1.R1 is a 73-year-old resident admitted to the facility on 2/11/04. R1’s diagnoses include: Alzheimer’s with agitation and psychosis as well as cogni-shunt placement. R1’s initial Minimum Data Set (MDS) dated 2/12/04 found that R1 has short and long term memory problems and is moderately impaired for making daily decisions. R1 was noted to wear an electronic monitoring device that activates at only the front doors of the facility. R1 was identified to have behaviors including: wandering with no rational purpose, socially inappropriate behaviors, and resisting care. R1 was observed by the surveyor to wander about the facility on 3/9/04 and 3/10/04 without staff assistance. Interview with Z1 on the afternoon of 3/10/04 found that R1’s mental function varies, and there was no way to judge if R1 would be safe to be outside the facility unassisted. R1’s physician was on vacation and was not able to provide input regarding R1’s ability to assess a dangerous situation.

R1’s care plan for wandering dated 2/12/04 found that the approaches toward this behavior included: an electronic monitoring device, trying to keep the resident at the nurses station. Fifteen-minute checks were added 2/24/04 and 1-to-1 supervision was added on 2/29/04 after the resident left the facility without the facility’s knowledge. Interview with E6 (care planning staff) in their office on the afternoon of 3/9/04 found that an initial care plan is prepared shortly after a resident is admitted and that R1 had been identified through assessments as at risk to wander.

2.On the evening of 2/29/04 R1 left the facility and was located at 111 Violet Lane, Carbondale, Illinois, by a private citizen. A police report of the incident indicated a call to the police department at 7:23 p.m. came from a citizen at the above address reporting a man sitting on the deck. The report further stated the police responded and located an elderly man at the address. The police contacted the facility and found that R1 was missing from the facility at that time. The facility retrieved R1 from the residence and R1 was returned to the facility unharmed. Facility records found that upon R1’s return to the facility R1 was assessed and was found to have no injuries. This was confirmed by interview with E4 (Director of Nursing) during the survey on 3/0/04.

3. Investigation of R1’s elopement found that R1 was last seen in the South hall near the nurses station at approximately 7:15 p.m. by E5 (CNA). E5 indicated that she was putting residents to bed and was checking R1 after each resident. E5 indicated she took 15-20 minutes to use a lift and perform incontinence care for a resident and then put the resident to bed. When E5 returned to the nurses station where R1 was previously sitting, R1 was missing. E5 immediately began searching for R1. E5 indicated that at times R1 wandered about the building but at this time R1 could not be located. E5 contacted E4 and an in-house search was started. E4 indicated that R1 will hide in the facility at times. Both E4 and E5 denied having heard any door alarms during this time frame. The facility’s investigation record indicated this was 7:40 p.m. and the police report indicated that the nursing home was contacted at 7:38 p.m. Interview with E4 indicated that E3 (Social Service Director) was contacted and she was in the Carbondale area and was returning in her care to search the immediate area. The in-house search was suspended when the police located R1 and R1 was returned to the facility. R1’s 15-minute log and the facility’s investigation confirm the above time.

4. An interview with Z2 on the evening of 3/10/04 found that R1 was located behind a residence on Violet Lane. Z2 indicated that R1 was squatting down and playing in the leaves when Z2 arrived. Z2 stated that R1 was confused when questioned and indicated he was in Hurst, IL. Z2 stated R1 was not afraid but was confused to location and time. R1 was able to provide his name but could not tell Z2 where he was headed or where he had come from. Z2 indicated that due to R1’s condition, they contacted the nursing home nearby. Z2 indicated that R1 was wearing a sweatshirt, pants, ball cap and house shoes at the time R1 was located and that it was cool and dark outside at the time.

5. The facility is located at 120 North Tower Road in Carbondale, Illinois. Tower Road is a main connecting artery between two East/West roads. It has moderate traffic flow. The facility sits at the front of their property with a large open field to the rear (West). To the North is a Church with a large lot and parking area. To the South and East are residential areas. R1 was found 3 houses down Violet Lane (approximately 1/10 of a mile) from the undeveloped rear edge of the facility’s property and 2 blocks West of Tower Road. At the rear of the facility’s property is a tree line separating the facility property from the residential area.

6. At the time of the elopement it was dark and the temperature was 48 degrees Fahrenheit per the local television station. This information was in the facility’s report and confirmed by interview with E1 (Regional Manager) and E2 (Administrator) during an interview in E2’s office on the afternoon of 3/9/04.

7. Per review of the facility’s investigation and interviews during the survey it was found that upon R1’s return to the building on 2/29/04, R1 was assessed for injury and found to be fine. At 8 p.m. on 2/29/04 staff initiated 1-1 staff supervision of R1. Z1 and R1’s physician were notified of the incident at 8:05 p.m. and at 8:30 p.m. additional door alarms were requested. Interview with E4 confirmed that when the door alarms were tested on the evening of 2/29/04, the South hall laundry hall exit door alarm was off when tested. E4 and E1 indicated that the alarm was reactivated, and an old alarm system was also put in place. E4 further removed possession of all door alarm keys from all but nursing staff.